Case Study: Knee Injury Treatment

Short case summary: 25 years old, female injured her right knee during basketball game. PCP evaluated her, gave her non-steroidal anti-inflammatory with P.T referral. Patient came 2 days after injury, with knee swelling and locking. . Patient pain and mechanism of injury are consistent with a medial meniscus injury.

Diagnostic test: McMurray’s test, was Positive with palpable click.

Reliability of McMurray’s test: Evans ET. al¹ demonstrated a low level of agreement between the two examiners with inter-tester agreements ranging from poor for reproduction of a medial sensation (Kappa = −0.10) to fair (K = +0.38) for lateral pain.

Validity of McMurray’s test: shortage of statistics in the literature increased the risk that the positive test criteria can change the test outcome, irrespective of whether the test was performed in the same manner on the same patient.¹

I will change my first choice. McMurray’s test alone is weak diagnostic tool for medial meniscus injury, the review² has demonstrated that the inter-tester reliability and sensitivity (sensitivity ranged from 27% to 70%, specificity figures (29-96%) of the McMurray’s test is relatively low.

Another reading meta-analysis³,supported to use joint line tenderness test, McMurray’s test, and Apley’s test. I will add the other two tests to get strong diagnostic evidence for medial meniscus injury. Three special tests-McMurray’s, joint line tenderness (JLT), and Apley’s were included in the meta-analysis. Sensitivity of McMurray’s test is 70.5 (95% CI: 67.4 to 73.4) and it’s specificity of 71.1 (95% CI: 69.3 to 72.9). Joint line tenderness sensitivity of 63.3 (95% CI: 60.9 to 65.7) and it’s specificity of 77.4 (95% CI: 75.6 to 79.1). Sensitivity of Apley’s test is 60.7 (95% CI: 55.7 to 65.5) and it’s specificity of 70.2 (95% CI: 68.0 to 72.4).

Another reading⁴ supported Thessaly’ Test at 5 and 20 degrees (Evidence obtained from high quality randomized controlled trials, prospective studies, or diagnostic studies).

Intervention: therapeutic exercises to restore muscular strength and aerobic fitness. I found two evidences for therapeutic exercise intervention. I think both are strong evidences. First one⁴:

The supervised exercise group was significantly better than the home-based group regarding Sports Activity Rating scale and hop tests (Evidence level B).the same guidelines recommended that, Clinicians should consider a clinic-based exercise program in patients following arthroscopic meniscectomy to increase quadriceps strength and functional performance(Evidence level B).

The second evidence⁵was meta-analysis and systematic review reported that: No studies described the effectiveness of exercise therapy compared to no exercise therapy in non-surgical patients with a meniscal lesion.

I will not change my previous decision about therapeutic exercise as the main choice intervention for two reasons: First, the clinical guidelines support that choice with level B evidence.

Second reason: although the second study is systematic review, meta-analysis study

It didn’t introduce a strong alternative to my choice.

Outcome measure: lower extremity function scale (LEFS SCALE): The test evaluate the impairment of a patient with lower extremity musculoskeletal condition or disorders. Test measures initial function, progress of function, and outcome to design functional goals. In my case I use the LEFS for medial meniscus injury outcomes. Questionnaire is asked about 4 level of performance in 20 task questions that patient perform in daily life. Minimal score is 0(complete disability) and maximum score is 80(complete functional level)

Minimal Detectable Change (MDC)⁶:Various Lower Extremity Injuries (medial meniscus injury): MDC= 9 points. Minimally Clinically Important Difference (MCID)⁶: Various Lower Extremity Injuries: MCID = 9 points.

According to, Binkley ET al⁶. The LEFS isvalid compared to the SF-36 in target population, and reliable. The LEFS Sensitivity to outcome change was higher than the SF-36 in this population. The LEFS is applicable for clinical situations for individual patients and research.

LEFS SCALE reliability: Test-retest Reliability, Various Lower Extremity Injuries: Excellent test-retest reliability for the entire sample (r = 0.86; 95% lower limit CI = 0.80) ⁶.

Interrater/Intra-rater Reliability: Various Injuries of Lower Extremity: Excellent interrater reliability (r = 0.84)⁶

LEFS SCALE validity: Construct Validity: Various Lower Extremity Injuries: Excellent correlations between the LEFS scores and the SF-36 physical function subscale and physical component summary scores (r = 0.80; 95% lower limit CI=.73) and (r = 0.64; 95% lower limit CI = 0.54), Poor correlation between the LEFS scores and the SF-36 mental component summary scores (r = 0.30; 95% lower limit CI = 0.14)⁶

Another reference reported that, Lower Extremity Functional Scale may be an alternative to the Western Ontario and McMaster Universities Osteoarthritis Index physical function scale.

I will not change the outcomes measurement (LEFS) for knee injuries, I personally, prefer LEFS scale for its ease way and quick appliance to the patient. More than one strong study support high evidence, validity and reliability of LEFS. : The LEFS has good measurement properties: test- retest reliability and cross-sectional construct validity and it could be an alternative to WOMAC-PF

If I change the outcomes measure I’ll use Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).Comparison between WOMAC scale and LEFS scale showed approximate results of strong evidence according to validity and reliability to the both scales.

References:

1. Evans PJ, Bell GD, Frank CY. Prospective evaluation of the McMurray test. Am J Sports Med. 1993; 21:604-608
2. Hing, W.,white, S.,Reid,D.,et al. Validity of the McMurray’s Test and Modified Versions of the Test: A Systematic Literature Review,. J Man Manip. Ther. 2009; 17(1): 22-35.doi: 10.1179/106698109790818250
3. Meserve BB, Cleland JA, Boucher TR A meta-analysis examining clinical test utilities for assessing meniscal injury, Clinical Rehabilitation 2008 Feb;22(2):143-61. doi:10.1177/0269215507080130.
4. Logerstedt D, Mackler L., Ritter R, et al., Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther. 2009:39
5. Swart N.M. , Oudenaarde K., Reijnierse M., et al., Effectiveness of exercise therapy for meniscal lesions in adults: A systematic review and meta-analysis, Journal of Science and Medicine in Sport, 2016-12-01, Volume 19, Issue 12, Pages 990-998.
6. Binkley JM, Stratford PW, Lott SA, et al., The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopedic Rehabilitation Research Network. Phys Ther. 1999 Apr; 79(4):371-83).
7. Pua YH, Cowan SM, Wrigley TV, et al., The Lower Extremity Functional Scale could be an alternative to the Western Ontario and McMaster Universities Osteoarthritis Index physical function scale, Journal of Clinical Epidemiology 62 (2009) 1103e1111).